Getting Started with Medicare Advanced Medicare Training

Medicare Made Clear™

Brought to you by UnitedHealthcare©

v This Medicare Counselor Training program was developed under a grant from UnitedHealthcare® through a joint project with the National Association of Area Agencies on Aging (n4a). However, nothing in these educational materials shall imply an n4a endorsement of any kind regarding UnitedHealthcare or its products and services or those of any Medicare Advantage, Medicare Prescription Drug or Medicare Supplement insurance plan. As a matter of practice, n4a does not endorse any insurance products or services.

1.  Determine a person's current Medicare coverage

2.  Learn about Medicaid and the qualifications to get assistance

3.  Educate about additional benefits that Medicare covers

4.  Answer common Medicare Part D questions

5.  Understand the filing, appeal and grievance process

Learning Objectives

1.  How can an individual determine what type of Medicare coverage they have?

2.  How does age and retirement affect a person's Medicare choices?

3.  What is the difference between Medicare and Medicaid?

4.  How do I know if a consumer qualifies for assistance?

5.  What are some additional benefits Medicare covers?

6.  What are common Medicare Part D questions?

7.  What is the process if someone needs to file an appeal and grievance?

Medicare Questions

QUESTION 1 How can an individual determine what type of Medicare coverage they have?

How can an individual determine what type of Medicare coverage they have?

Original Medicare (Parts A & B) Original Medicare + Part D Plan

Original Medicare + Medicare Supplement

If an individual only uses their Medicare card issued by the federal government.

If an individual has a Medicare card plus a separate drug plan card. A discount card for drugs does not mean they have a Part D plan.

If an individual uses their Medicare card along with a card for Medicare supplement insurance that helps pay some of the expenses that Medicare doesn’t.

Original Medicare + Medicare Supplement + Part D Plan

If an individual has three cards that include a Medicare card, a Part D drug plan card as well as a Medicare Supplement card that covers expenses Medicare doesn't cover.

COVERAGE 1

Medicare Advantage (Part C) Medical Only + Part D (included)

Medicare Advantage (Part C) Medical Only + Part D (separate)

If a member only uses a health plan card instead of their Medicare card from the federal government for medical and drug coverage.

If a member uses a health plan card for their medical coverage and a second health plan card for their drug coverage expenses.

COVERAGE 1

How can an individual determine what type of Medicare coverage they have?

True or False: Once you enroll in Medicare, you must give up any other health care coverage you have.

COVERAGE 1

True or False: Consumers can have a Medicare Advantage plan and a Medicare Supplement insurance plan.

COVERAGE 1

True or False: You can change your Medicare Advantage or prescription drug plan once a year during Medicare Open Enrollment, October 15 through December 7.

COVERAGE 1

QUESTION 2 How does age and retirement affect a person’s Medicare choices?

Retiring before 65: •  Retiree coverage •  Individual health insurance •  COBRA

Retiring at 65: •  Medicare coverage •  Possible employer-sponsored coverage

CHOICES 2

How does age and retirement affect a person’s Medicare choices?

True or False: When a person first enrolls in Medicare, it’s a good idea for them to speak with their current health plan benefits administrator to see how their coverage may work with Medicare.

CHOICES 2

Continuing to work after 65 •  Retiree plans may coordinate with Medicare •  Coverage if consumers keep working

Retiring after 65 •  Eligible for a Special Enrollment Period (SEP) •  Coverage if consumers keep working

Note: If consumers do not sign up during their Initial Enrollment Period (IEP), they may have to pay a penalty fee for as long as they are in Medicare if they do not have creditable coverage.

CHOICES 2

How does age and retirement affect a person’s Medicare choices?

QUESTION 3 What is the difference between Medicare and Medicaid?

Medicare A federal health insurance program for people who are: •  65 or older •  Under 65 with certain disabilities •  Of any age and have End Stage Renal Disease (ESRD) Medicaid A joint federal and state program that helps pay health care costs for certain people and families with limited income and resources. Note: A person can be eligible for both Medicare and Medicaid.

PLANS 3

What is the difference between Medicare and Medicaid?

PLANS 3

Dual Special Needs Plan are a type of Medicare Advantage (Part C) plan designed for people with special needs. These plans combine hospital care and doctor’s visits and other outpatient care in a single plan •  DSNPs provide focused and specialized health

care for people who are eligible for both Medicaid and the Medicaid assistance program, sometimes called “dual eligibles”.

•  Dual eligible individuals have the option to enroll or switch plans at any time of the year.

•  DSNPs are run by private insurance companies.

What is a Dual Special Needs Plan (DSNP)?

QUESTION 4 How do I know if a consumer qualifies for assistance programs?

Medicare Savings Program •  Helps people pay their Part A and Part B premiums, deductibles

and co-insurance amounts Program of All-Inclusive Care for the Elderly (PACE) •  Combines medical, social and long-term care services for the

frail elderly who live in and get their health care services in the community, not in a nursing home

Prescription Drug Premium Assistance Programs •  Help people pay some or all of their Medicare Part D premiums

and cost sharing, incudes the Extra Help or Low-Income Subsidy program

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Medicare Savings Programs Types of programs that help pay Parts A and B premiums,

Who is eligible? •  States set their own income eligibility levels, but the average is

close to $17,820 per year for an individual, or $24,030 for a married couple.

Resources that count toward assets: •  Funds in a checking or savings account •  Stocks •  Bonds

Resources that do NOT count toward assets: •  Their home •  A car •  Furniture and other household and personal items •  Burial plot •  Up to $1,500 in burial expenses •  Collectibles

Note: States set their own income eligibility levels, but the average is close to <XX>.

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Qualified Medicare Beneficiary (QMB)

Specified Low-Income Medicare Beneficiary (SLMB)

Qualified Individual (QI)

Qualified Disabled and Working Individual (QDWI)

$1,010 / $1,355

$1,208 / $1,622

$1,357 / $1,823

$4,045 / $5,425

$7,280 / $10,930

$7,280 / $10,930

$7,280 / $10,930

$4,000 / $6,000

Medicare Savings Program Individual / Couple Monthly Income Limits*

Individual / Couple Resources Limits*

States set their own income eligibility levels. *Numbers are from 2016.

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Qualified Medicare Beneficiary (QMB) QMB Only Requirements: •  Income and resources are within limits listed in chart

•  Does not qualify for any additional Medicaid benefits

QMB Plus Requirements: •  Income and resources are within limits listed in chart •  Qualifies for additional Medicaid benefits

QMB Only pays for: Medicare premiums, deductibles, co-pays and co-insurance (not including Part D) QMB Plus pays for: Medicare premiums, deductibles, co-pays and co-insurance as well as benefits under the State Medicaid plan (not including Part D)

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Specified Low-Income Medicare Beneficiary (SLMB) SLMB Only Requirements: •  Income and resources are within limits listed in chart •  Does not qualify for any additional Medicaid benefits

SLMB Plus Requirements: •  Income and resources are within limits listed in chart •  Qualifies for full Medicaid benefits

SLMB Only pays for: Medicare Part B premium SLMB Plus pays for: Medicare Part B premium and qualifies for full Medicaid benefits

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Qualified Individual (QI) Requirements: •  Income and resources are within limits listed in chart

QI Pays for: Medicare Part B premium.

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Qualified Disabled and Working Individual (QDWI) Requirements: •  Income and resources are within limits listed in chart

QI Helps pay for: Medicare Part A premium for certain working disabled Medicare beneficiaries who have exhausted their entitlement to a premium-free Part A benefit.

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Extra Help or Low Income Subsidy (LIS) Full Subsidy Requirements: •  Individual / couple monthly income $1,357/$1,823

•  Individual / couple resources $8,780/$13,930

Partial Subsidy Requirements:

•  Individual / couple monthly income $1,505/$2,023

•  Individual / couple resources $13,640/$27,250

LIS helps pay for: Some or all of a person’s Medicare Part D premiums, deductibles and co-pays or co-insurance.

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

True or False: Extra Help or Low Income Subsidy (LIS) helps pay for some or all of a person’s Medicare Part B premiums, deductibles and co-pays or co-insurance.

QUALIFICATION 4

Other Full Benefit Dual Eligible (FBDE): Requirements: •  Meet State Medicaid/MSP financial eligibility

•  Eligible for Medicaid either categorically or through optional coverage groups based on medically needy status, special income levels for institutionalized individuals or home and community-based waiver.

States set their own income eligibility levels.

FBDE may cover: The Part B premium, deductibles, co-pays and co-insurance (varies by state) and qualifies for full Medicaid benefits

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

Program of All-Inclusive Care for the Elderly (PACE)

PACE combines: Medical, social and long-term care services for frail elderly people who live in the community, not a nursing home States set their own income eligibility levels.

QUALIFICATION 4

How do I know if a consumer qualifies for assistance programs?

QUESTION 5 What are some additional benefits of Medicare coverage?

QUESTION 5 What are some additional benefits that Medicare covers?

Durable Medical Equipment Medicare Part B covers doctor prescribed durable medical equipment for use at home, including: •  Braces (arm, leg, back and neck) •  Crutches •  Oxygen supplies and therapy •  Some diabetic supplies •  Therapeutic shoes or inserts •  Walkers •  Wheelchairs •  And more

In order to qualify, medical equipment must be: •  Used for a medical reason •  Used in their home •  Durable (or long-lasting) •  Not useful for someone who isn’t sick or

injured The doctor or supplier needs to be enrolled in Medicare and accept the assignment.

Note: Consumers will be responsible for the 20% co-insurance of the Medicare-approved amount.

5 BENEFITS

What other benefits does Medicare covers?

Covered •  Original Medicare (Parts A and B) covers skilled nursing care and therapy,

such as speech therapy or physical therapy, for the homebound •  Part B covers emergency transportation to a hospital, critical access hospital

or skilled nursing facility when it is absolutely needed

Not covered •  Dental, optical and hearing is not covered under Original Medicare (Parts A

and B)

For services that aren’t covered, consumers need to get separate insurance from an insurance company or pay the full cost for the services.

5 BENEFITS

What other benefits does Medicare covers?

QUESTION 6 What are common questions about Medicare Part D?

What vaccines does Medicare cover?

What drugs are covered under Part B

versus Part D? How is the coverage

gap changing?

•  Flu: Part B covers a shot once per flu season in the fall and winter

•  Shingles: Not covered under Parts A or B, but generally covered under Part D

•  Pneumonia: Part B covers a shot once

•  Hepatitis B: Covered by Part B

•  Diphtheria, tetanus and whooping cough: Covered by Part B

•  Part B covers some prescription drugs

•  Examples include:

•  Infused drugs •  Antigens •  Osteoporosis drugs •  Erythropoiesis

(stimulating agents) •  Blood clotting factors •  Injectable drugs •  Oral ESRD •  Immunosuppressive

drugs •  Oral anti-cancer and

anti-nausea drugs •  Self-administered drugs in

outpatient settings

•  Patient Protection and Affordable Care Act (PPACA) is gradually reducing the coverage gap

•  More than 1 million seniors and people with disabilities saved $687 million on prescription drugs in the donut hole

•  It is expected that discounts will increase each year until the coverage gap closes. (Projected for 2020)

PART D 6

What are common questions about Medicare Part D?

True or False: Medicare Part B covers flu, diphtheria, tetanus and whooping cough vaccines.

PART D 6

Member can ask their doctor or pharmacist if another drug on the formulary will work

Change to Another Drug

Transition Supply

Step Therapy

Member may be able to request a temporary supply of the drug

Member may be required to try one or more similar drugs before the plan will cover the medication

Approval from the health plan before the drug will be covered

Prior Authorization Exception

Member and doctor can ask the plan for an exception

If a drug isn’t covered, there are options:

PART D 6

What are common questions about Medicare Part D?

QUESTION 7 What is the process if a person wants to file an appeal and grievance?

Five Tips from Medicare on filing an appeal: 1.  Gather information 2.  Ask the plan for a fast decision 3.  The plan will review its decision 4.  Right to a immediate review 5.  Right to a fast-track appeals process

APPEALS 7

What's an appeal? An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan.

Tips on filing an appeal

APPEALS 7

Hospital Inpatient Status: When a patient is formally admitted to a hospital with a doctor’s order

•  Covered under Medicare Part A and B

Hospital Observation Status: When doctors don’t know what care a patient may need but the patient is too sick to get care in the doctor’s office

•  Covered under Medicare Part B •  Viewed as outpatient care

What is the difference between hospital inpatient status and observation status?

Medicare is the primary payer if: •  The consumer is at least 65 years old, is still working, and

is covered by a group health plan through an employer with less than 20 employees.

•  The consumer is at least 65 and covered by a retiree health plan through a former employer (of any size).

APPEALS 7

Payer: The party responsible for paying health care bills.

Medicare with other health insurance: Who Pays First?

Note: * Plan F also comes in a high-deductible version, under which you must pay for Medicare-covered costs up to the deductible amount of $2,180 in 2015 before your Medigap plan pays anything.

**100% after you reach your yearly out-of-pocket limit. ***$20 copay for doctor visit and $50 copay for ER visit.

10 Standard Medicare Supplement Plans

Benefits CoveredPlan

APlan

BPlan

CPlan

DPlanF*

PlanG

PlanK

PlanL

PlanM

PlanN

Part A hospital coinsurance and 365 extra hospital days 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Part A deductible 100% 100% 100% 100% 100% 50%** 75%** 50% 100%

Part B coinsurance or copays 100% 100% 100% 100% 100% 100% 50%** 75%** 100%

100% except certain

co-pays***

Part B annual deductible 100% 100%

Part B excess charges 100% 100%

APPEALS 7

What are the differences between Medicare supplement plans?

Note: *Plan F also comes in high-deductible version, under which you must pay for Medicare-covered costs up to the deductible amount of $2,180 in 2016 before your Medigap plan pays anything. **100% after you reach your yearly out-of-pocket limit ***$20 copay for doctor visit and $50 copay for ER visit.

APPEALS 7

What are the differences between Medicare supplement plans? (continued)

Note: *Plan F also comes in high-deductible version, under which you must pay for Medicare-covered costs up to the deductible amount of $2,180 in 2016 before your Medigap plan pays anything. **100% after you reach your yearly out-of-pocket limit ***$20 copay for doctor visit and $50 copay for ER visit.

Note: * Plan F also comes in a high-deductible version, under which you must pay for Medicare-covered costs up to the deductible amount of $2,180 in <2016> before your Medigap plan pays anything.

**100% after you reach your yearly out-of-pocket limit. ***$20 copay for doctor visit and $50 copay for ER visit.

10 Standard Medicare Supplement Plans

Benefits CoveredPlan

APlan

BPlan

CPlan

DPlanF*

PlanG

PlanK

PlanL

PlanM

PlanN

Cost of blood transfusion 100% 100% 100% 100% 100% 100% 50%** 75%** 100% 100%

Cost of foreign travel emergency (up to the 80% 80% 80% 80% 80% 80%

Hospice care 100% 100% 100% 100% 100% 100% 50%** 75%** 100% 100%

Part B preventive care coinsurance 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Skilled nursing facility 100% 100% 100% 100% 50%** 75%** 100% 100%

Yearly out-of-pocket limit (<2016>)

No limit

No limit

No limit

No limit

No limit

No limit $4,960 $2,480 No

limitNo limit

QUESTIONS?

This Medicare Counselor Training program was developed under a grant from UnitedHealthcare through a joint project with the National Association of Area Agencies on Aging (n4a). However, nothing in these educational materials shall imply an n4a endorsement of any kind regarding UnitedHealthcare or its products and services or those of any Medicare Advantage, Medicare Prescription Drug or Medicare Supplement insurance plan. As a matter of practice, n4a does not endorse any insurance products or services. Copyright ©2016 United Health Care Service, Inc. All rights reserved. No portion of this work may be reproduced or used without express written permission of United HealthCare Services, Inc., regardless of commercial or non commercial nature of the use. Not for distribution to retirees or beneficiaries. SPRJ22770 IR_160329_162019

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